Download High suspicion of cancer definitions April 2016

Faster Cancer Treatment:
High suspicion of cancer definitions
April 2016
Page i
Contents
Introduction ............................................................................................................. iii
1.
Breast ............................................................................................................ 1
2.
Bowel ............................................................................................................ 2
3.
Gynaecological .............................................................................................. 3
4.
Head and Neck............................................................................................... 4
5.
Lung .............................................................................................................. 7
6.
Lymphoma .................................................................................................... 8
7.
Melanoma ..................................................................................................... 9
8.
Myeloma ..................................................................................................... 10
9.
Sarcoma ...................................................................................................... 11
10.
Thyroid ........................................................................................................ 14
11.
Upper GI ...................................................................................................... 15
Page ii
Introduction
The following definitions have been developed by clinically-led tumour standards working groups to
support achievement of the Faster cancer treatment (FCT) health target by clarifying what constitutes
a ‘high suspicion of cancer’ for ten tumour streams.
Faster cancer treatment health target
85 percent of patients receive their first cancer treatment (or other management) within
62 days of being referred with a high suspicion of cancer and a need to be seen within two
weeks by July 2016, increasing to 90 percent by June 2017.
The FCT health target builds on the significant improvements that have been made in the
quality of cancer services over recent years. It provides a lens across the whole cancer
pathway to ensure people have prompt access to excellent cancer services.
The following points are applicable across all definitions:
A resource for triaging(or prioritising) clinicians
The definitions have been developed for use, in the first instance, by triaging (or prioritising) clinicians
within secondary and tertiary care who are responsible for determining or confirming the ‘high
suspicion of cancer’ flag. DHBs are encouraged to consider how the definitions can be adapted and
used to support improved detection and referral of patients with a high suspicion of cancer from
primary care.
Apply to the ‘high suspicion of cancer’ component of the health target
To be included within the FCT health target cohort a patient must have both a high suspicion of cancer
and a need to be seen within two weeks. The definitions only apply to the 'high suspicion of cancer'
component of the FCT health target and are not intended to define the urgency of the referral. The
triaging clinician will need to make a separate assessment of whether a patient meets the criteria of
needing to be seen within two weeks.
Guidance to help inform clinical judgement
The definitions are intended as guidance to help inform clinical judgement. If other
features/symptoms/signs exist that raise concerns, the triaging clinician can still choose to triage as
‘high suspicion of cancer’.
Risk factors have been included for some tumour types
Some tumour streams have included risk factors to support their high suspicion of cancer definitions,
with particular consideration of specific factors that that may influence the triaging process. It should
also be noted that Māori present with cancer at an earlier age than non-Māori across all tumour types.
Referrals with a positive fine needle aspiration and/or biopsy
Patients referred though an outpatient pathway with a positive fine needle aspiration (FNA) and/or
biopsy for cancer at the time the referral is received within secondary/tertiary care should be triaged
as having a high suspicion of cancer (rather than a confirmed cancer) and included within the FCT
health target cohort. This is because these patients will require further investigations and assessment
before a confirmed diagnosis and decision on treatment is made. It also supports direct access to
diagnostics from primary care.
Page iii
1.
Breast
BREAST CANCER1
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
Diagnosed cancer on fine needle aspiration or core biopsy (or results suspicious of
malignancy)
Imaging suspicious of malignancy
Discrete, hard breast lump with fixation (with or without skin tethering)
Discrete breast lump that presents in women with one or more of the following:

age 40 years or older, and persists after her next period or presents after
menopause

aged younger than 40 years and the lump is increasing in size or where there are
other reasons for concern (see risk factors below), such as strong family history

with previous breast cancer or ovarian cancer
Suspected inflammatory breast cancer or symptoms of breast inflammation that have not
responded to a course of antibiotic
Spontaneous unilateral bloody nipple discharge
Women aged over 40 years with recent onset unilateral nipple retraction or distortion
Women aged over 40 years with unilateral eczematous skin or nipple change that does not
respond to topical treatment
Men aged 50 years and older with a unilateral, firm sub-areolar mass, which is not typical
gynaecomastia or is eccentric to the nipple
1
Risk Factors:
 A first degree relative diagnosed with breast cancer before aged 50 years
 Two or more first degree relatives on the same side of the family diagnosed with breast cancer at any age
 Two second degree relatives on the same side of the family, diagnosed with breast cancer, at least one before
age 50
 First or second degree relative diagnosed with bilateral breast cancer
 First or second degree relative with male breast cancer
 Known to carry a breast cancer susceptibility gene mutation (e.g. BRCA1 or BRCA2)
 Radiation Therapy delivered to the chest or mediastinum
Page 1
2.
Bowel
BOWEL CANCER2
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
Known or suspected bowel cancer (on imaging, or palpable or visible on rectal examination)
Unexplained rectal bleeding (benign anal causes treated or excluded) WITH iron deficiency
anaemia (haemoglobin and ferritin below the local reference range)
Altered bowel habit (looser and/or more frequent) > 6 weeks duration PLUS unexplained
rectal bleeding (benign anal causes treated or excluded) AND aged ≥ 50 years
2
Please note that these criteria are for high suspicion of cancer that would warrant direct access colonoscopy within
two weeks - it is not an exhaustive list of the possible manifestations of bowel cancer that may warrant colonic
investigation. Please interpret this guideline in conjunction with Referral Criteria for Direct Access Outpatient
Colonoscopy (Ministry of Health, December 2012) and Guidance on Surveillance for People at Increased Risk of
Colorectal Cancer (New Zealand Guidelines Group, 2011).
Page 2
3.
Gynaecological
GYNAECOLOGICAL CANCER
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
Biopsy-proven or cytology positive gynaecological malignant or premalignant disease3 or
Gestational Trophoblastic Disease
A visible abnormality suspicious of a vulval, vaginal or cervical cancer (such as an exophytic,
ulcerating or irregular pigmented lesion)4
Significant symptoms (including abnormal vaginal bleeding, discharge or pelvic pain)
AND
Abnormal clinical findings suspicious of gynaecological malignancy (including
lymphadenopathy, vaginal nodularity or pelvic induration)5
Post-menopausal bleeding. (N.B. High suspicion of cancer may be excluded if physical
examination, smear and vaginal ultrasound are normal6)
A rapidly growing pelvic mass or genital lump7
Women with a palpable or incidentally-found pelvic mass (including any large complex
ovarian mass >8 cm) UNLESS investigations (ultrasound and tumour markers) suggest
benign disease8
Women with a documented genetic risk who have a suspicious pelvic abnormality or
symptoms9
Please see National Cervical Screening Programme recommendations for colposcopy referral.
Women with an undiagnosed visible genital abnormality which is not highly suspicious of malignancy should be
referred for gynaecological or dermatology review or undergo a biopsy.
5
Women with gynaecological abnormalities or symptoms may also have gynaecological malignancy and the
development of triage pathways is encouraged. Specific consideration includes premenopausal women with
abnormal uterine bleeding. Those with persistent or deteriorating symptoms should be reviewed by a
gynaecologist. A raised CA125 supports the need for further investigation in woman with persistent pelvic or
abdominal symptoms.
6
Early access to vaginal ultrasound will reduce demand on secondary services. Women without post-menopausal
bleeding but with a thickened endometrium should undergo gynae review but are not defined as high risk.
7
Discernible growth within a 3 month period is normally of concern. Undiagnosed external genital lumps with any
discernible growth should normally be reviewed by a gynaecologist and/or biopsied.
8
The development of referral pathways is recommended to ensure rapid assessment of patients with a pelvic mass,
early access to pelvic ultrasound is seen as crucial to this process.
N.B. Suspicion of ovarian malignancy is indicated by metastatic disease, ascites or radiologist’s impression, a
raised CA125 in a post-menopausal woman or germ cell markers in a woman under 25. The risk of malignancy
index (RMI) is utilised to triage patients for subspecialty care.
9
Usually women with strong family history or known hereditary nonpolyposis colorectal cancer (HNPCC) or BRCA
mutations.
3
4
Page 3
4.
Head and Neck
HEAD AND NECK CANCER - Oral/Throat/Lip Lesion10
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
A visible or palpable Oral, Throat, or Lip Lesion and one or more of the following:
10

unexplained ulcer/lesion/lump persisting for > 3 weeks

leukoplakia – must be either nodular, swollen, or bleeding (flat leukoplakia requires
standard referral)

erythroplakia

unexplained tooth mobility/ non-healing socket

persistent numbness chin, lip, palate or tongue
Risk factors:





Smoking history
Excess alcohol intake
Immunosuppression
Betel nut
Previous history of mouth cancer
Page 4
HEAD AND NECK CANCER - Neck/Salivary Lump11
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
An unexplained neck/salivary mass and one or more of the following:
11

mass > 1cm and persisting > 3weeks

mass is increasing in size

previous head and neck cancer including skin cancer

facial palsy

any new unexplained upper respiratory tract symptoms such as hoarseness,
dysphagia, throat or ear pain, blocked nose or ear
Risk factors:




Smoking history
Excess alcohol intake
Past history of head and neck cancer
Immunosuppression
Page 5
HEAD AND NECK CANCER - Upper aerodigestive tract12
If the patient presents with one or more of the following red flags (new unexplained symptoms > 3
weeks), then the referral should be triaged as ‘High Suspicion of Cancer’.
Red flags
YES or NO
New throat pain or referred otalgia
New hoarseness with a history of smoking
New progressive dysphagia to solids or liquids (excluding isolated globus sensation)
Stridor/upper airway noise
New nasal obstruction associated with another red flag
New epistaxis associated with another red flag
12
Risk factors:




Smoking history
Excess alcohol intake
Past history of head and neck cancer
Immunosuppression
Page 6
5.
Lung
Lung Cancer
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
Chest x-ray or other imaging suggestive/suspicious of lung cancer (including new pleural
effusion, pleural mass, and slowly resolving consolidation)
Persistent or unexplained haemoptysis in high risk13 individuals over 40 years of age
New pathological diagnosis of lung cancer
Notes for referrer:
A. An urgent chest X-ray is required for lung cancer in people aged 40 and over if they have:
 Any persistent or unexplained haemoptysis
 Unexplained/persistent (more than 3 weeks)
o
cough
o
shortness of breath
o
chest/shoulder pain
o
weight loss greater than 10%
o
Abnormal chest signs
o
Unresolved chest infection
o
hoarseness
 Finger clubbing
 Features suggestive of metastasis from a lung cancer (e.g. in brain, bone, liver or skin) as part of
appropriate work up
 Cervical and/or persistent supraclavicular lymphadenopathy
Any person who has been referred for an urgent chest x-ray for the above indications and has been
found with consolidation should have a repeat chest x-ray 6 weeks later to confirm resolution.
B. Chest x-ray normal. If any symptoms or signs detailed above persist for longer than 6 weeks despite a
normal chest x- ray, consider referral to respiratory services.
C. Mesothelioma. Suspected mesothelioma should also be triaged as above. It is essential that a
careful career history is taken to identify any possible occupations at high risk of asbestos exposure.
All symptoms related to SVC obstruction, spinal cord compressions, airway obstruction, and massive
haemoptysis, are medical emergencies and should be referred appropriately.
13
High risk factors
When making a decision to refer, assess and document risk factors for lung cancer. These include:

smokers or ex-smokers

history of exposure to asbestos,

pre-existing lung disease particularly COPD or interstitial lung disease

history of cancer

family history of lung cancer
It should be noted the incidence of non-smoking related cancer is increasing particularly in women and East Asians
Page 7
6.
Lymphoma
LYMPHOMA
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’
Red flags
YES or NO
Lymphadenopathy persistent for 4 weeks or lymph nodes rapidly increasing in size
(otherwise unexplained)
Lymph nodes > 2cm, widespread nature, firm, non-tender
Unexplained drenching night sweats or fevers or weight loss of greater than 10% of body
weight
Radiology suspicious for lymphoma
Page 8
7.
Melanoma
MALIGNANT MELANOMA OF SKIN
Red flags
EITHER:
Skin lesion AND three or more of the following features:
A.
Asymmetry of shape, structure or colour
Y/N
B.
Border irregularity
Y/N
C.
Colour variation / multiple colours
Y/N
D.
Different from other lesions (‘ugly duckling’)
Y/N
E.
Evolving, changing
Y/N
Risk factors
Personal history of melanoma
Y/N
Family history of 2+ first degree relatives <40 yrs diagnosed with
melanoma
Y/N
OR:

Dermoscopy of skin lesion is suspicious for melanoma
Y/N
IN ADDITION:
All referrals must include the following supporting results:
Required: Size of lesion
(space to write size)
Required: Body location
(attachment or
description)
(space to write
location)
Required: Digital macroscopic image of lesion
(attachment)
If available: Dermoscopic image of lesion
(attachment)
Page 9
8.
Myeloma
MYELOMA - Plasma cell neoplasms
If the patient presents with the following red flags, then the referral should be triaged as ‘High Suspicion
of Cancer’.
Red flags
YES or NO
M-protein in serum and/or urine and one or more of the following

otherwise unexplained hypercalcaemia (> 2.75 mmol/L)

otherwise unexplained renal impairment – creatinine clearance <40 ml/min

otherwise unexplained anaemia – Hb <100g/L

bony lytic lesions on radiologic imaging

serum monoclonal protein (IgG or IgA >30g/L or involved:uninvolved serum free
light chain ratio >10014
14
The serum free light chain ration is currently defined (nationally) as a Tier 2 test, which means the test cannot be
requested in primary care without cost to the patient.
Page 10
9.
Sarcoma
SARCOMA - Soft tissue lumps (adults 15 years and older)
If the patient presents with the following red flags, then the referral should be triaged as ‘High Suspicion
of Cancer’.
Red flags
YES or NO
An unexplained soft tissue mass and one or more of the following

mass size > 5cm in size

increasing in size

deep to fascia

painful

radiology suspicious for malignancy

a recurrence after previous excision
Page 11
SARCOMA - Soft tissue lumps (children up to 15 years)15
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
An unexplained soft tissue mass and one or more of the following

mass size >2cm in size

increasing in size

deep to fascia

painful

radiology suspicious for malignancy

unexplained presence of one or more of the following:
-
proptosis
-
persistent unilateral nasal obstruction
-
aural polyps and/or aural discharge
-
urinary retention
-
blood-stained vaginal discharge
-
scrotal swelling
15
Children under the age of 16 years are not included within the Faster Cancer Treatment health target. Sarcoma
have included high suspicion of cancer definitions for children as an educational tool to raise awareness of the
signs/symptoms of sarcoma in children.
Page 12
SARCOMA - Bone cancer (adults and children)16
If the patient presents with the following red flags, then the referral should be triaged as ‘High Suspicion
of Cancer’.
Red flags
YES or NO
An unexplained bony mass and one or more of the following

palpable mass fixed to bone

increasing in size

radiology suspicious for malignancy

a recurrence after previous excision

suspected spontaneous fracture

unexplained presence of one or more of the following:
-
increasing or persistent bone pain (especially at rest)
-
night pain
-
limp (for a child)
16
Children under the age of 16 years are not included within the Faster Cancer Treatment health target. Sarcoma
have included high suspicion of cancer definitions for children as an educational tool to raise awareness of the
signs/symptoms of sarcoma in children.
Page 13
10. Thyroid
THYROID CANCER
If the patient presents with thyroid swelling and one or more of the following red flags, then the referral
should be triaged as ‘High Suspicion of Cancer’.
Red flags
YES or NO
Thyroid swelling and one or more of the following:

unexplained voice change or stridor

thyroid nodule in a child

cervical lymphadenopathy

painless thyroid mass rapidly enlarging, i.e. over a period of 2-3 months

family history of multiple endocrine neoplasm

cytology result indicating a high risk of cancer, ie Bethesda 5-617
17
Although Bethesda 4 does not necessarily constitute a high suspicion of cancer, review by an endocrinologist or
surgeon is required (risk of malignancy being up to 30%).
Page 14
11. Upper GI
UPPER GI CANCER - Stomach Cancer18
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
Unexplained weight loss with one or more of the following:

upper abdominal pain in patient aged > 40yrs

dyspepsia

nausea and vomiting

haematemesis /melaena

new onset heartburn
Upper abdominal mass consistent with stomach cancer
Dysphagia (new onset or progressive)
Māori or Pacific of any age with a family history of stomach cancer and one or more of the
following:
18











upper abdominal pain

dyspepsia

reflux symptoms
Risk factors for stomach cancer, which when present increases the suspicion
Excess alcohol intake
Smoking
High animal fat diet
Socio-economic deprivation
Previous gastric surgery
Helicobacter pylori infection
Type A blood
Immune deficiency
Family history of first degree relatives with stomach cancer
Genetic syndromes (hereditary diffuse gastric cancer (CDH1), hereditary non-polyposis colorectal cancer
(HNPCC), familial adenomatous polyposis (FAP, BRCA1 and 2, Li-Fraumeni syndrome, Peutz Jeher syndrome).
Investigations that would be consistent with an increased risk of stomach cancer:
 Iron-deficient anaemia/low ferritin
 Platelet count
 H.pylori infection
 Endoscopy findings of chronic gastritis
Page 15
UPPER GI CANCER - Oesophageal Cancer19
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
Dysphagia (new onset and/or progressive)
Unexplained weight loss in patients > 55 years with one or more of the following:

upper abdominal pain

new onset heartburn

dyspepsia

nausea/vomiting

upper abdominal pain
Haematemesis/melaena
Māori or Pacific of any age with family history of oesophageal cancer with one or more of
the following:
19











upper abdominal pain

new onset heartburn

dysphagia (new onset or progressive)

dyspepsia
Risk factors for oesophageal cancer which when present increases the suspicion
Age over 55 years
Smoking
Male
High animal fat diet
Longstanding Gastro-Oesophageal Reflux Disease (GORD)
Barrett’s metaplasia of the oesophagus
Previous gastric surgery
Socio-economic deprivation
Obesity/BMI >35
Excess alcohol intake
Investigations that would be consistent with an increased risk of oesophageal cancer
 Endoscopy findings of long segment Barrett’s (>3cm)
 Iron-deficient anaemia/low ferritin
 Elevated platelet count
Page 16
UPPER GI CANCER - Pancreatic Cancer20
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
Painless obstructive jaundice
Unexplained weight loss with one or more of the following:
20






new-onset diabetes

new onset mid-back discomfort

steatorrhoea

nausea/vomiting
Risk factors for pancreatic cancer (which when present increases the suspicion):
Smoking
Obesity/BMI >35
Chronic pancreatitis, especially with mass
Family history of first degree relatives with pancreatic cancer;
Genetic syndromes (hereditary breast and ovarian cancer syndrome, familial melanoma, familial pancreatitis,
hereditary non-polyposis colorectal cancer, Peutz-Jeghers syndrome, Von Hippel-Lindau syndrome)
Investigations that would be consistent with an increased risk of pancreatic cancer
 Cholestatic liver dysfunction
 New onset diabetes
 HbA1c>41 (pre-diabetes)
 Elevated CEA and/or Ca19-9
Page 17
UPPER GI CANCER - Biliary/Gallbladder Cancer21
If the patient presents with one or more of the following red flags, then the referral should be triaged as
‘High Suspicion of Cancer’.
Red flags
YES or NO
Painless obstructive jaundice
Abdominal mass consistent with a gallbladder tumour
21




Risk factors for biliary/gallbladder cancer (which when present increases the suspicion):
Polyps (>1 cm)
Gallstones (>20 years)
Porcelain gallbladder
Primary sclerosing cholangitis
Investigations that would be consistent with an increased risk of biliary/gallbladder cancer
 Cholestatic liver dysfunction
 Ultrasound ± CT showing asymmetric wall thickening or mass in gallbladder or bile duct
 Elevated CEA and/or Ca 19-9
Page 18
UPPER GI CANCER - Liver Cancer22
If the patient presents with the following red flag, then the referral should be triaged as ‘High Suspicion
of Cancer’.
Red flags
YES or NO
Upper abdominal mass consistent with enlarged liver and one or more of the following:

unexplained weight loss

jaundice

risk factor(s)
21. Risk







factors for liver cancer (which when present increases the suspicion):
Previous history of bowel cancer
Chronic viral hepatitis (B or C)
Cirrhosis
Heavy alcohol consumption
Family history of primary liver cancer
Haemachromatosis
Inherited metabolic disease
Investigations that would be consistent with an increased risk of biliary/gallbladder cancer:
 US/CT/MR showing mass(es) in liver
 Elevated AFP and/or CEA and/or Ca 19-9
 Liver dysfunction including increased INR and decreased albumin
Page 19